The nurse is assessing a 28 year old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations take immediate priority?
a) oral temperature of 100 b) tachypnea and restlessness c) frequent loose stools d) weight loss of 1 pound since yesterday
b) tachypnea and restlessness
In prioritizing care, the pneumonia would first be assessed by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take precedence over a temperature or tachypnea and restlessness. An oral temperature of 100 is not considered a fever and would not be the first thing addressed.
A patient has been newly diagnosed with AIDS. The patient is a 32 year old mother of two young children. When you are doing your initial assessment, the patient expresses fear of dying. How should the nurse best respond to the patient?
a) " would you like someone to talk to ?" b) "everyone dies eventually" c) " you are afraid of death; what concerns you most about death" d) " you may live for several years"
c) " you are afraid of death; what concerns you most about death"
The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with open-ended question to help facilitate the patient to identify fears about being diagnosed with a life-threatening chronic illness.
A nurse is preparing an educational event for a local community group. The topic is HIV prevention. The nurse is aware that teaching related to the prevention of HIV should focus on what?
a) vaccinating all individuals to decrease their risk of contracting HIV b) providing educational programs that focus on control and prevention c) instructing sexually active individuals on the proper usage of nonlatex condoms d) instructing sexually active individuals on the use of the microbicide, nonoxynol-9 (N-9)
b) providing educational programs that focus on control and prevention
Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Primary prevention efforts through effective educational programs are vital for control and prevention. The nurse should instruct the patient on the proper use of condoms, but only latex condoms should be used during vaginal or anal intercourse. Nonlatex condoms are available for people with latex allergy, but will not protect against HIV infection. Also, based on recent research studied and their results, the CDC issued recommendations in 2000 that intravaginal application of N-9 should not be recommended as an effective means of HIV prevention.
The nurse instructor is going over labratory results for HIV/AIDS patients. The instructor tells the students that upon interpretation of patient's lab results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what?
a) 200 cells/mm of blood b) 300 cells/mm blood c) 400 cells/mm blood d) 500 cells/mm blood
a) 200 cells/mm of blood
When the CD4 T-cell levels drop below 200 cells/mm of blood, the person is said to have AIDS. Patient's with the CD4 levels greater than 200 is considered to have HIV
A patient with AIDS is being prepared for discharge. The nurse caring for the patient with AIDS knows the patient recieves Agenerase. What dietary counseling will the nurse provide based upon the patient's medication regimen?
a) avoid high-fat meals while taking this medication b) limit fluid intake to 2 liters a day c) limit sodium intake to 2 grams per day d) avoid meals high in protein while taking this medication
a) avoid high-fat meals while taking this medication
Patients taking the protease inhibitor Amprenavir (APV) or Agenerase should be advised to avoid high-fat meals. High fat meals decrease the blood concentration of this dryg by 21%. Patients taking either of these drugs can take the drug with or without regard to meals, but the meals should not be high in fat. Fluid, sodium, and protein restrictions play no role in relation to either of these drugs.
While orienting to her new postion on a telemetry floor a graduate nurse (GN) works with a preceptor. The graduate nurse's preceptor identifies that the novice nurse will need additional instruction on Standard Precautions when she observes which of the following behaviors?
A) The GN wears face protection, gloves, and a gown when irrigating a wound b) the GN washers her hands with a waterless antiseptic agent after removing a pair of soiled gloves c) th GN puts on a second pair of gloves over her soiled gloves while performing a bloody procedure d) The GN places a used needle and syringe in the puncture-resistant container without capping the needle
c) th GN puts on a second pair of gloves over her soiled gloves while performing a bloody procedure
The preceptor must intervene when she observes the graduate nurse placing another pair of gloves over a soiled pair of gloves. The GN must be instructed to change her gloves after contact with materials that may contain high concentration of microorganisms (such as blood or any body fluid) even when working with the same patient. After removing the soiled gloves, the GN must be instructed to wash her hands before donning the new pair of gloves. The GN was correct to avoid recapping the used needle before discarding it in the puncture-resistant container. Also, the GN anticipated that irrigation of a wound may lead to splashing or the generation of droplets and she assembled and wore the proper protective attire. After the removal of a pair of gloves, the GN was correct in washing her hands.